Detect and prevent the risk of developing a psychotic disorder
Summary
The concept of "high-risk mental state for psychosis" (EMARS) describes mild psychotic symptoms that indicate a high risk of developing psychosis, with studies indicating that approximately 22% of young people who present with these symptoms develop a psychotic disorder three years later. Knowing this is a very important advance in the early detection of psychosis.
The study of these risk states has as one of its main objectives to find those variables that can identify the people most vulnerable to having psychosis and, therefore, carry out interventions that can prevent or delay the transition. But also to treat the symptoms, which can cause enough emotional distress to have to ask for help. The approaches that are recommended can be of two types: pharmacological and psychosocial. Cognitive behavioral therapies and activities that reduce stress and anxiety have shown benefits in improving the quality of life of these people.
The concept of " high-risk mental state for psychosis (EMARS) " -or high clinical risk for psychosis- refers to the presence of a series of signs and symptoms similar to those of psychosis , but which occur in an attenuated manner. These symptoms are considered to define a state of risk, because a significant percentage of people who present with them may end up developing psychosis in the future.
Thus, one of the main objectives of the study of high-risk mental states is to be able to detect in time children, adolescents or young adults who are at risk of developing psychosis in the short or medium term, in order to be able to carry out specific monitoring and apply an intervention that can prevent or postpone this transition, as well as to reduce the discomfort associated with these states. (Yung et al., 2021). This is therefore an important advance in the early detection of psychosis.
Factors that increase the risk of having a psychosis
Symptoms that define high-risk mental states
The criteria for defining the risk of psychosis most accepted by all research groups are those established by the European Psychiatric Association (Schultze-Lutter, 2015), based on the presence of one or more of the following syndromes:
- Brief intermittent psychotic syndrome (BLIPS). Clear presence of positive psychotic symptoms (delusions, hallucinations or alterations in thinking and communication), of recent onset and short duration.
- Attenuated positive psychotic symptoms syndrome. Presence of positive psychotic symptoms (delusions, hallucinations, or disturbances in thinking or communication), which occur in a mild or attenuated manner. Often the person may realize that they are experiencing the symptom and it creates a feeling of strangeness or doubt about whether what they are perceiving is real or not.
- Genetic risk and functional impairment syndrome. It is the combination of having a genetic risk for a schizophrenia spectrum disorder and, at the same time, having functional impairment. Genetic risk is considered when you have a relative with a diagnosis of a psychotic disorder, whether affective (bipolar disorder) or non-affective (schizophrenia spectrum disorder). Genetic risk is also considered if the person is diagnosed with schizotypal personality disorder. This condition must occur together with impairment of functioning.
Evolution of mental states at high risk of psychosis
Research studies using the described clinical criteria that define these states have found that transition rates, that is, the number of people with this syndrome who end up developing a psychotic disorder, in young adults is 22%, three years after being diagnosed with the at-risk state (Fusar-Poli et al., 2020). In other words, when these people are followed for three years, three out of ten end up developing a psychotic disorder .
The application of this concept to children and adolescents is even more recent (Tor et al., 2018) and, therefore, less data is available. However, published data suggest a similar transition rate [Catalan et al., 2020; Armando et al., 2020), although there is no total agreement in the scientific community and some current studies show lower rates (Lång et al., 2022).
One in four people with a high-risk mental state for psychosis will develop a psychotic disorder three years later. Knowing this is a very important advance in the early detection of psychosis.
In this population, the possibility is also assessed that attenuated psychotic symptoms in childhood and adolescence may also be part, in some cases, of normative brain development processes or as a consequence of adaptive mechanisms to the environment, and not indicative of an imminent risk of developing a psychotic disorder [Schultze-Lutter et al., 2015; Schimmelmann et al., 2015].
The scientific community continues to research, but there is agreement to highlight that the childhood and adolescent period is a crucial time for the prevention of this disorder in this population (Kelleher, 2023).
The importance of primary care in the detection of psychosis
Preventing psychosis and treating discomfort
When addressing these states, two issues must be taken into account:
- The importance of preventing the transition to a psychotic state.
- The importance of treating the symptoms present in order to reduce discomfort.
Preventing psychosis
One of the main objectives of current research into these risk states is to find transition markers , that is, to find those variables (biological, neuroimaging, clinical, psychological or neuropsychological) that can differentiate people who end up developing a psychotic disorder from those who do not, despite having these risk states. If these differential markers can be identified, it will be possible to identify the most vulnerable people and, therefore, to carry out interventions that can prevent or delay the transition to psychosis.
In this sense, clinical variables are those that show the highest evidence in predicting which people will develop a psychotic disorder (Fusar-Poli et al., 2020; Oliver et al., 2020):
- The initial severity of the attenuated psychotic symptoms: the more severe they are, the greater the likelihood of developing a psychotic disorder.
- The initial severity of attenuated negative psychotic symptoms: the more severe these symptoms are, the greater the risk of developing the disorder.
- The person's overall level of functioning: the lower the functioning in daily life, the greater the risk of developing a psychotic disorder.
Other variables that may be related have been studied, such as biological markers (related to vulnerability to stress, such as cortisol); emotional variables (cognitive schemas, the ability to cope with difficulties or manage stress); changes in brain structure (studies related to gray and white matter neuroimaging) or cognitive variables (differences in the cognitive capacity of people at risk). But for now, none of them show a high level of evidence.
In high-risk mental states, the symptoms of psychosis are attenuated, but they cause discomfort to the person. Psychosocial measures aimed at reducing the stress and anxiety that the person experiences are beneficial in improving their subjective experience.
It is therefore suggested that the risk of developing psychosis is multifactorial , that is, it is a combination of all these clinical, biological and psychological/psychosocial variables, and, therefore, at the moment there is no clear and definitive guidance regarding which interventions may be best to prevent the onset of these disorders (Fusar-Poli et al., 2020).
Treating discomfort
Regardless of whether or not people with these risk syndromes may develop a psychotic disorder, the symptoms they present often cause them enough emotional distress to have to seek help.
The approaches that are recommended can be of two types: pharmacological and psychosocial (Schmidt et al., 2015).
Pharmacological interventions
From a pharmacological point of view, the guidelines recommend not treating with antipsychotic drugs with the sole purpose of preventing the transition. However, if the attenuated psychotic symptoms generate enough emotional distress, such that the person has a very unpleasant experience, or interfere with the person's ability to lead a normal or satisfactory life (prevent them from socializing with peers or family, make it difficult to maintain academic or work activity, etc.), then antipsychotic drugs may be prescribed.
On the other hand, there are also other types of medications that can help alleviate symptoms related to anxiety, mood symptoms, etc., which are usually associated with these risky mental states.
Psychosocial interventions
Regarding psychosocial interventions, although there is no single intervention that is indicated, all psychosocial measures aimed at reducing the stress and anxiety that the person experiences are beneficial for improving their subjective experience and their ability to function well.
In this sense, both occupational, recreational, relational, etc. measures are useful, as are more specific psychological interventions to reduce and manage anxiety or cope with symptoms.
Cognitive behavioral therapies or interventions designed to treat anxiety disorders are the ones that show the most evidence. In recent years, the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders , which aims to reduce the associated symptoms of anxiety and depression, has also been applied and proven to be effective for these syndromes. The application of acceptance and commitment techniques and other psychotherapeutic interventions may also be indicated, depending on the case.
Recently, interventions derived from dialectical behavioral therapy , adapted to these syndromes, are also being applied, and could also be effective interventions depending on the case and the predominant symptoms.
Since there is no single intervention specifically designed for these states, it is recommended to design a plan for each case , based on existing and scientifically proven interventions for other disorders or problems.
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